Provider Demographics
NPI:1679854772
Name:ROGERS, HEATHER DIANE (DDS)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:DIANE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11820 SW KING JAMES PL
Mailing Address - Street 2:SUITE 10J
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-2480
Mailing Address - Country:US
Mailing Address - Phone:503-616-5000
Mailing Address - Fax:
Practice Address - Street 1:11820 SW KING JAMES PL
Practice Address - Street 2:SUITE 10J
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-2480
Practice Address - Country:US
Practice Address - Phone:503-616-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6551-151223G0001X
ORD99431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice